A 55-year-old man comes to the emergency department due to rectal pain. The pain, which is described as excruciating and unrelenting, started abruptly 2 hours ago while the patient was having a bowel movement. He denies fevers, abdominal pain, hematochezia, or unexpected weight loss. Medical history is significant for chronic constipation. Temperature is 37.5 C (99.5 F), blood pressure is 125/75 mm Hg, pulse is 75/min, and respirations are 12/min. The abdomen is nontender and nondistended. Rectal examination reveals an exquisitely tender, purplish bulge just below the dentate line. Which of the following is the immediate next step in management?

Question

A 55-year-old man comes to the emergency department due to rectal pain.  The pain, which is described as excruciating and unrelenting, started abruptly 2 hours ago while the patient was having a bowel movement.  He denies fevers, abdominal pain, hematochezia, or unexpected weight loss.  Medical history is significant for chronic constipation.  Temperature is 37.5 C (99.5 F), blood pressure is 125/75 mm Hg, pulse is 75/min, and respirations are 12/min.  The abdomen is nontender and nondistended.  Rectal examination reveals an exquisitely tender, purplish bulge just below the dentate line.  Which of the following is the immediate next step in management?

Quizplus · Accepted Answer

11ec25c8_d83d_3778_bc81_8342410a9627_MD0003_00 This patient with severe anorectal pain and a purplish anal bulge below the dentate line has a thrombosed external hemorrhoid. Hemorrhoids form as a result of venous hypertension within the hemorrhoidal venous plexus. Intravascular inflammation can lead to mucosal ulceration and ultimately thrombosis. This complication usually occurs with external hemorrhoids, although internal hemorrhoid thrombosis may occur. Hemorrhoid thrombosis causes excruciating anorectal pain associated with an easily identifiable purple or blue bulge within the anorectum. At times, the thrombosis may be visible as a palpable cord within the hemorrhoid itself. Although conservative management is recommended in mild cases, external hemorrhoidectomy is indicated for those with severe pain. This surgery, which can be performed under local anesthesia, is performed by making an elliptical excision in the skin surrounding the hemorrhoid, enabling its complete extraction. If surgery is delayed, temporary relief can be achieved by hemorrhoidal incision and thrombus removal; however, recurrence is common, so a hemorrhoidectomy should eventually be performed. (Choices B and C) Infrared coagulation, rubber band ligation, and sclerotherapy are all used to treat symptomatic nonthrombosed internal hemorrhoids that fail conservative management. These techniques are avoided with external hemorrhoids because their location below the dentate is highly innervated and these procedures would cause severe pain. (Choices D and E) In patients with mild and nondebilitating pain, thrombosed external hemorrhoids can resolve with conservative management consisting of stool softeners, sitz baths, and topical anti-inflammatories and antispasmodics (eg, glucocorticoid suppositories, nitroglycerin cream). This patient has excruciating pain, necessitating more definitive and immediate surgical intervention. Antibiotics are indicated for perirectal abscesses but are not usually required in the treatment of thrombosed hemorrhoids. Educational objective: Thrombosed external hemorrhoids usually appear as purple or blue anal bulges below the dentate line and may cause severe pain. Although conservative management (eg, fiber, stool softeners, topical anti-inflammatories and antispasmodics) is usually indicated, patients with severe pain should undergo hemorrhoidectomy under local anesthesia. References: Hemorrhoids: from basic pathophysiology to clinical management. (http://www.ncbi.nlm.nih.gov/pubmed/22563187)

A 55-Year-Old Man Comes to the Emergency Department Due to Rectal